Narrative Notes as a Reflection of a Nurse’s Critical Thinking

Nursing is not just about performing tasks, administering medications, or ensuring patient comfort; it’s a dynamic process that involves deep critical thinking, decision-making, and problem-solving. One of the most effective ways nurses communicate their observations, interpretations, and decisions is through narrative notes. These notes serve as a comprehensive reflection of a nurse’s clinical judgment and are an essential part of patient care documentation.

This blog will explore how narrative notes provide insight into a nurse’s critical thinking skills, focusing on the process of observation, interpretation, and decision-making. Additionally, we will provide examples of well-written narrative notes to illustrate how critical thinking is demonstrated through this essential form of documentation.

The Role of Narrative Notes in Nursing Practice

Narrative notes are a vital component of the patient’s medical record. They allow nurses to document patient conditions, responses to interventions, and any relevant changes in health status. Unlike structured documentation (such as checklists or flow sheets), narrative notes provide more detailed, descriptive accounts of the nurse’s observations and the reasoning behind clinical decisions.

For a nurse, documenting care is more than just a task—it’s an opportunity to reflect on the care provided, assess the patient’s needs, and plan for further interventions. This documentation process demands critical thinking, as the nurse must sift through various observations, interpret them, and decide on an appropriate course of action.

Critical thinking is defined as the ability to think in a systematic, logical way to understand and solve complex problems. In nursing, critical thinking is applied through the process of assessment, diagnosis, planning, implementation, and evaluation (ADPIE), where each step involves thoughtful analysis and decision-making. Narrative notes act as a written record of these critical thinking processes, helping healthcare teams stay informed about a patient’s progress and ensure continuity of care.

The Process of Observation in Narrative Notes

Critical thinking in nursing begins with effective observation. Observation is the act of gathering information about the patient’s condition through physical assessments, monitoring of vital signs, and even communication with the patient or family members. These observations form the foundation for subsequent actions and decisions.

Narrative notes showcase a nurse’s ability to recognize important details during assessments and document them clearly. For instance, a nurse might observe a patient’s change in skin color, noting any signs of pallor or cyanosis. These observations are not just recorded as facts; they are analyzed, interpreted, and acted upon.

Here is an example of how observation might be documented in a narrative note:

“Upon assessment at 0900, the patient appeared slightly flushed with a temperature of 101°F. The skin on the forehead and chest was warm to the touch, indicating a possible fever. The patient stated feeling ‘chilly’ but denied chills. Vital signs were taken, and the heart rate was 98 bpm, respiratory rate 18 bpm, and blood pressure 130/80 mmHg.”

In this note, the nurse has described the patient’s appearance, their subjective report, and the vital signs. The temperature and skin assessment indicate that the nurse is closely monitoring the patient’s condition for signs of infection, fever, or other concerns that might require further intervention.

Interpretation of Observations

Once a nurse has gathered data through observation, the next step is interpretation. Interpretation involves analyzing the observed information in the context of the patient’s overall clinical picture. This step requires the nurse to apply their knowledge of disease processes, medical history, and potential complications.

Critical thinking is essential during this phase because the nurse needs to distinguish between normal variations and potential red flags. Interpretation allows the nurse to understand the significance of a symptom and anticipate what might happen next. It involves a decision-making process where the nurse asks, “What does this data mean, and what should I do about it?”

Let’s consider a scenario where the nurse notices signs of dehydration:

“The patient reports dry mouth and has a decreased urine output since yesterday. Upon further assessment, the skin turgor is slightly reduced, and the patient appears lethargic. The patient’s current fluid intake has been less than normal, as they have been refusing water due to nausea. The patient’s blood pressure is slightly low at 100/60 mmHg, and their heart rate is elevated at 110 bpm.”

In this note, the nurse is interpreting the patient’s symptoms of dry mouth, reduced urine output, and low blood pressure in the context of potential dehydration. The nurse does not just record these facts—they analyze them within the framework of the patient’s overall condition, history, and current state.

Decision-Making in Narrative Notes

The final step in the critical thinking process is decision-making. After making observations and interpreting the data, the nurse must determine the best course of action. In some cases, this may involve implementing immediate interventions, while in others, the nurse might choose to monitor the patient more closely or consult with other members of the healthcare team.

Narrative notes serve as an excellent medium for documenting the decision-making process. In these notes, nurses justify their clinical decisions, explain the reasoning behind interventions, and sometimes predict potential outcomes.

Consider the following example of a well-documented decision:

“Based on the assessment findings and the patient’s complaints of nausea and vomiting, I have decided to initiate a rehydration protocol. I have ordered IV fluids to be administered at 100 mL/hr, and I will monitor for any changes in the patient’s vital signs, particularly blood pressure and heart rate. I have informed the attending physician of the findings and the proposed interventions. The patient will be re-assessed in 2 hours for any further changes.”

In this note, the nurse’s decision-making process is clearly outlined. The nurse has considered the patient’s clinical presentation, reviewed the available data, and chosen an appropriate intervention. The nurse also anticipates the patient’s needs moving forward and ensures that other healthcare providers are informed.

The Importance of Well-Written Narrative Notes in Reflecting Critical Thinking

The ability to write clear, concise, and well-organized narrative notes is crucial for reflecting a nurse’s critical thinking. A well-written narrative note not only provides accurate documentation of the patient’s condition but also communicates the nurse’s reasoning process to other members of the healthcare team. This promotes continuity of care and ensures that decisions made by the nurse are transparent and easy to follow.

Effective narrative notes should have several key characteristics:

1. Clarity and Accuracy: Notes should accurately describe the patient’s condition, including both objective data (e.g., vital signs, lab results) and subjective data (e.g., patient-reported symptoms).

2. Organization: Narrative notes should be well-structured and easy to follow, often written in chronological order or in a way that reflects the nurse’s thought process.

3. Conciseness: While it’s important to provide detailed information, the note should avoid unnecessary jargon or overly long descriptions.

4. Rationale for Actions: Good narrative notes include the rationale behind clinical decisions, showing the thought process that led to specific interventions.

5. Future Considerations: Anticipating the next steps and potential changes in the patient’s condition is important. Notes should reflect the nurse’s proactive approach to care.

Examples of Well-Written Narrative Notes

Let’s look at a couple of examples that demonstrate critical thinking through narrative notes.

Example 1: Respiratory Distress

“At 1500, patient was observed to have increased work of breathing, with audible wheezing and use of accessory muscles. Oxygen saturation was 89% on room air. The patient’s respiratory rate was 24 breaths per minute, and pulse oximeter readings decreased to 85% after 10 minutes of activity. The patient reports a history of asthma and states they have not used their inhaler in the last 12 hours. Administered albuterol nebulizer treatment as per protocol. Oxygen therapy initiated at 2L/min via nasal cannula. Patient’s condition improved after 10 minutes, with O2 saturation rising to 94%. Will continue to monitor closely for changes.”

In this example, the nurse documents the observations, interprets the patient’s symptoms, and makes a decision to administer treatment. The narrative clearly outlines the patient’s response to interventions, showing the nurse’s ability to adjust care based on real-time assessment.

Example 2: Post-Surgical Recovery

“At 0800, the patient, post-hip replacement, reports pain level of 6/10, stating that it’s mostly localized in the surgical site. Upon assessment, the patient’s vital signs are stable: BP 120/75, HR 80, RR 16, Temp 98.2°F. The dressing is intact with no signs of infection. Encouraged the patient to begin passive range-of-motion exercises to prevent stiffness. Administered prescribed pain medication (hydrocodone 5 mg PO) and will reassess pain in 30 minutes. Discussed post-operative care instructions with the patient, including mobility restrictions and signs of infection. Will continue monitoring for signs of complications such as deep vein thrombosis or wound infection.”

Here, the nurse effectively records the patient’s subjective and objective data, interprets the pain level, and makes decisions on pain management and patient education. The note also reflects the nurse’s anticipation of potential post-surgical complications.

Conclusion

Narrative notes are an essential tool for documenting a nurse’s critical thinking and decision-making processes. By observing, interpreting, and making decisions based on their observations, nurses demonstrate their clinical reasoning skills. Well-written narrative notes serve as a valuable resource for other healthcare professionals and promote continuity of care. Through these notes, nurses not only communicate vital information but also reflect on their role as active, critical participants in the healthcare process. In the fast-paced and demanding world of nursing, critical thinking and thoughtful documentation are key to providing the best care possible.